Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: January 9, 2025

Observations: Licensing toured the facility and observed wall damage on the first floor, including peeling baseboards and baseboards held to the wall by tape.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the electronic Medication Administration Record (eMAR) and observed that all medications for persons in care were signed and coded for by staff.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: a recreation and leisure plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the care plans for six persons in care and observed that each person in care had a recreation and leisure plan.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the medication carts and did not observe any medications that had expired.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations: